The Time for Action Is Now: The Impact of Timing of Infectious Disease Consultation for Staphylococcus aureus Bacteremia.

This retrospective cohort study was performed to compare clinical outcomes between patients with Staphylococcus aureus bacteremia who received an early versus late infectious disease consultation. Early consultation resulted in significantly greater adherence to quality care indicators and shorter hospital stays.

Acute HIV presenting as rhabdomyolysis.

A man, in his early 30s, with no significant medical history presented with a 2-week history of fatigue, chest and abdominal pain, associated with anorexia and vomiting. Initial laboratory testing was suggestive of rhabdomyolysis with acute renal failure and transaminitis. The aetiology of his rhabdomyolysis initially remained unexplained as there were no clear risk factors or inciting events. An extensive workup revealed acute HIV as the precipitant of rhabdomyolysis.

First case of Arcobacter species isolated in pericardial fluid in an HIV and COVID-19 patient with worsening cardiac tamponade.

Arcobacter spp. is an emerging pathogen that is increasingly recognized as a cause of human infections. Gastrointestinal manifestations are most described in the case report literature. We present a case of the first documented case of Arcobacter spp. isolated in pericardial fluid in an immunocompromised patient with worsening cardiac tamponade that was successfully managed with an urgent pericardiocentesis and ensuing steroids, antibiotics, and a pericardial drain. The patient had a past medical history of HIV, latent syphilis, PCP pneumonia, ESRD, and hypertension, and presented with worsening dyspnea, subjective fever, myalgias, cough, pleuritic chest pain, and pericardial rub. Diagnostic workup revealed a positive COVID-19 PCR test, elevated high-sensitive cardiac troponins, elevated CRP, elevated D-dimer, and elevated creatinine. An ECG revealed diffuse ST-segment elevation, and imaging showed cardiomegaly with pulmonary vascular congestion and diffuse interstitial edema. Urgent TTE showed a large circumferential pericardial effusion with tamponade physiology present. Culture on aerobic blood agar grew Arcobacter spp. of unknown specific species, and blood cultures were also positive for Arcobacter spp. Treatment involved intravenous meropenem for five days, followed by oral ciprofloxacin, low-dose colchicine, and a tapered dose of ibuprofen. Repeat laboratory data and TTE showed complete resolution of the pericardial effusion and improved left ventricular function. This case highlights the potential for Arcobacter spp. to cause severe infections and the importance of considering it as a possible pathogen in patients with atypical presentations.

Fusariosis: An Invasive Fungal Disease in a Neutropenic Patient With Acute Myeloid Leukemia.

Although rare in the U.S invasive Fusariosis (IF) is increasingly being recognized as a cause of severe invasive fungal disease in patients with neutropenia in the setting of hematologic malignancy and hematopoietic stem cell transplants (HSCT). IF in these patients is associated with high mortality, moreover there are no guidelines on effective therapy, thus early diagnosis and involvement of an expert with experience in treating Fusariosis are imperative. We present a case of IF in a patient with profound prolonged neutropenia in the setting of chemotherapy for relapsed, refractory acute myeloid leukemia. A 33-year-old woman with relapsed acute myeloid leukemia (AML) was hospitalized for re-induction chemotherapy. Five days post cycle 1 she became neutropenic. She was treated with prophylactic antimicrobials that included acyclovir, levofloxacin, and Posaconazole. On day sixty she began to run a high-grade fever. The physical exam was remarkable for a temperature of 102 degrees Fahrenheit and a heart rate of 116 beats per minute. Complete blood count was remarkable for 130 WBC/ml, Hb 6.5 g/dl, hematocrit (HCT) 18.7%, 13000 platelets/ml, absolute neutrophils counts (ANC) of 0. Her CT chest showed new bilateral lung nodules. Antibiotics were changed to cefepime, vancomycin, and metronidazole on day sixty-two without response. On day sixty-five meropenem was started and cefepime stopped. On day sixty-eight posaconazole was stopped and amphotericin B was started and two days later fever became low grade. She developed hyperpigmented skin lesions with necrotic centers on extremities that were biopsied. Histopathology staining favored the presence of rare fungal hyphae. The culture of the biopsy sample grew Fusarium spp that was identified by DNA sequencing as Fusarium falciforme. Voriconazole and terbinafine were added. Her fevers resolved within the next 24 hours and she remained afebrile. Fusarium is a hyaline mold present in the environment. Infection is acquired by inoculation into the skin, intravascular devices, or inhalation. IF incidence is low in the United States. F. solani and F. oxysporum are the most predominant disease-causing species complexes. Invasive Fusariosis (IF) is a rare disease seen in patients with hematologic malignancy and hematopoietic stem cell transplants (HSCT) with profound neutropenia. Immunocompromised patients suffer disseminated disease to multiple sites as in this case, with mortality rates of between sixty to eighty percent in this patient population. Blood and skin lesions biopsy cultures are diagnostic. Blood cultures are positive in up to sixty percent of cases in about four days. Polymerase chain reaction (PCR) can identify Fusarium but species identification by PCR is difficult. Newer molecular methods are better for species identification. Histopathology can be helpful. Differential diagnoses include invasive aspergillosis (IA), mucormycosis, mycobacterial and dimorphic fungal infections. There are no guidelines for standard therapy. Amphotericin B or voriconazole are preferred. Combination therapy may be indicated. Neutrophil recovery is crucial. Adjunctive and preventive measures have roles.

Strongyloidiasis Infection As the Cause of Pancreatitis.

Strongyloidiasis is endemic to socioeconomically disadvantaged tropics and subtropics, primarily as an asymptomatic carriage. It is seen in developed nations among the underprivileged. We describe a case of an Asian immigrant with eosinophilia, common bile duct stricture, cholangitis, and pancreatitis with Strongyloides spp. found on duodenal biopsy in the setting of steroid exposure.

Aerococcus urinae Infective Endocarditis.

Aerococcus urinae is a gram-positive organism frequently found in the urinary tract. It is often mistaken for Streptococcus and Enterococcus based on its appearance. It commonly causes urinary tract infections but has rarely been associated with fatal infective endocarditis and sepsis. We present a case of Aerococcus urinae infective endocarditis and discuss echocardiographic imaging findings and management approach.

Fungemia due to Aureobasidium pullulans.

Aureobasidium pullulans is a yeast-like dematiaceous fungus ubiquitous in nature. It is a rare cause of skin and soft tissue infection, peritonitis, and catheter-related fungemia in certain human hosts. We report a case of recurrent A. pullulans catheter-related fungemia that was successfully treated with caspofungin, posaconazole, and catheter removal.

A Case Report of Melioidotic Prostatic Abscess in a Traveler.

A 48-year-old man who had returned from Panama 5 weeks prior presented with fever, dysuria, hematuria, flank pain, and suprapubic pain and was found to have a prostatic abscess. Abscess fluid obtained during transurethral drainage grew Burkholderia pseudomallei. Blood cultures remained negative, and imaging did not show any other visceral abscess. This presentation of primary prostatic melioidosis is extremely rare in this region.

High pyocyanin production and non-motility of Pseudomonas aeruginosa isolates are correlated with septic shock or death in bacteremic patients.

Studies of the outcome of Pseudomonas aeruginosa bacteremia (Pab) have focused mainly on antibiotic appropriateness. However, P. aeruginosa possesses many virulence factors whose roles in outcomes have not been examined in humans, except for the type III secretion system (T3SS) toxins. The purpose of this study was to examine the role of virulence factors other than the T3SS toxins. Bacterial isolates were collected from 75 patients who suffered from Pa blood stream infections. Host factors such as neutropenia, immunosuppression, comorbidities, time to effective antibiotics, source of bacteremia, and presence of multidrug resistant (MDR) isolate were studied. The isolates were analyzed for the presence of toxin genes, proteolytic activity, swimming and twitching motility, and pyocyanin production. The data were analyzed to ascertain which virulence factors correlated with poor outcomes defined as septic shock or death (SS) within 7 days. Septic shock or death occurred in 25/75 patients. Univariate analysis identified age as a host factor that exerted a significant effect on these outcomes. Ineffective antibiotics administered during the first 24 hours of treatment or MDR P. aeruginosa did not influence the frequency of SS, nor did the presence of lasB, exoA, exoS exoU, plcH genes and proteolytic activity. However, 6/8 patients infected with non-motile isolates, developed SS, p = 0.014 and 5/6 isolates that produced large amounts of pyocyanin (>18ug/ml), were associated with SS, p = 0.014. Multivariate analysis indicated that the odds ratio (OR) for development of SS with a non-motile isolate was 6.8, with a 95% confidence interval (CI) (1.37, 51.5), p = 0.030 and with high pyocyanin producing isolates, an OR of 16.9, 95% CI = (2.27, 360), p = .017. This study evaluating the role of microbial factors that significantly effect outcomes following Pa bloodstream infection suggests that P. aeruginosa strains showing high pyocyanin production and the lack of motility independently increase the risk of SS.

Pseudoseptic Arthritis in a Patient With Psoriasis.

A 42-year-old male with a history of untreated psoriasis and a previous episode of presumed left knee septic arthritis developed sudden onset of left knee pain, swelling, and a moderate effusion. The pathogen could not be isolated despite extensive inflammation seen in synovial fluid (SF) and synovial tissue biopsy. Whether this is culture-negative septic arthritis or pseudo-septic arthritis is the enigma, given the limited sensitivity of current available SF microbiologic testing. We present a challenging and stimulating case with no current guidelines for an optimal empiric antibiotic regimen or anti-inflammatory therapy.

Elusive Enterobacter cloacae causing pacemaker endocarditis.

An 80-year-old patient was admitted for fever, chills, and chest wall pain. He had a past medical history significant for heart failure with a cardiac resynchronization therapy pacemaker implantation. Extensive workup revealed Enterobacter cloacae endocarditis of the pacemaker leads and the mitral valve, a rare etiology with an unidentified source in our patient. He was managed with a rather unconventional method which proved to be successful. This case sheds light on non-HACEK (other than Haemophilus spp., Aggregatibacter actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, or Kingella spp). gram-negative organisms, and particularly E. cloacae, as uncommon causes of endocarditis with elevated mortality, and discusses potential treatment modalities.

Bartonella Endocarditis: A Missed Diagnosis in Medical Practice.

Here, we present the case of a 52-year-old patient who presented with fever, chills, and weight loss. Further workup revealed Bartonella endocarditis of the aortic valve. After six weeks of antibiotics, a follow-up transthoracic echocardiogram showed a decrease in the size of vegetation. Serologic testing based on epidemiologic history should be obtained for the workup of blood culture-negative endocarditis.

Miliary Histoplasmosis in a Renal Transplant Patient.

Solid organ transplant (SOT) recipients are at increased risk of opportunistic infections due to significant T-cell immune dysfunction. The incidence of clinical disseminated histoplasmosis is rare, and its variable clinical presentation and response to therapy make it challenging to treat with resultant high mortality. A high index of clinical suspicion is necessary, especially in non-endemic areas. We report our clinical experience treating a 63-year-old renal transplant patient on immunosuppressive therapy with late-onset acute miliary histoplasmosis initiated on liposomal amphotericin B (L-AmB).

Liberation from Dialysis Dependence in a Patient with HIV-Associated Nephropathy (HIVAN) after Combined Antiretroviral Therapy (cART).

Prior to the advent of combined antiretroviral therapy (cART), human immunodeficiency virus-associated nephropathy (HIVAN) was inevitably associated with rapidly progressive renal failure and dialysis dependence. HIV-1 seropositive patients often met with untimely deaths due to complications of end-stage renal disease (ESRD), opportunistic infections, or other HIV-related end-organ failure. Although the association between cART and improved outcomes in HIVAN has been recognized for over 20 years, no randomized trials have specifically examined this effect to date. In terms of reversal of dialysis-dependent renal failure after cART initiation, only a handful of case reports exist. The authors report a case of a 44-year-old Latino male requiring thrice-weekly haemodialysis in the setting of biopsy-proven HIVAN who was able to stop dialysis in 7 months after being initiated on cART.